A Rare Case of a Distal Humerus Pathological Fracture from Klebsiella Pneumoniae Osteomyelitis: A Case Report.

Klebsiella pneumoniae is one of the leading causative organisms in pyogenic liver disease. It can cause disseminated infections, but rarely to bone, and rarely in healthy hosts. We report an unusual case of a distal humerus fracture from osteomyelitis secondary to dissemination in a non-immuno-compromised patient. The patient was surgically managed with external fixation and insertion of anti-biotic beads, in conjunction with medical therapy via culture direct antibiotics. This report highlights the diagnostic approach and treatment options for these atypical cases.

Survey of consultants in restorative dentistry in the UK regarding ongoing care of patients provided with dental implants.

Background Funding for implant-based treatment within secondary care is limited, and acceptance criteria are determined locally according to funding agreements with NHS England. Indefinite review of all patients in secondary care is unlikely to be feasible due to limitations on departmental capacity. The increasing number of patients provided with implant-based treatment in secondary care has resulted in a growing maintenance burden, raising the question of who should provide this care. Management of some complications within primary care would facilitate patients' access to treatment, although no specific provision for maintenance of implant-retained prostheses is made within the NHS Dental Charges Regulations.Materials and methods An online survey was carried out to review services provided within restorative dentistry departments across the UK, investigating departmental protocols for review and maintenance of patients provided with dental implants.Results There was no consensus view on review protocols, discharge or provision of maintenance following implant placement. Fifty-seven percent would indefinitely carry out remake of implant-retained overdentures when clinically indicated, replace worn inserts, housings or abutments. Sixty-one percent would manage loose/lost screw- or cement-retained restorations and 68% would manage fractured restorations. Re-referral for peri-implant disease would be accepted by 64% of respondents. The lack of clear NHS funding for the management of complications was of concern to respondents in this survey.

The management of traumatic tooth loss with dental implants: Part 1.

Traumatic dental injuries are relatively common causes of emergency presentation to general dental practitioners. There are well established guidelines for the management of traumatised teeth, which practitioners should be familiar with and able to deliver. Some teeth, however, are either lost at the time of injury or are found to have a hopeless long-term prognosis despite appropriate treatment. The first article in this two-part series covers the important aspects of maintaining teeth where possible, to preserve the supporting hard and soft tissues. It then describes the replacement of a single tooth lost due to trauma and the relative challenges faced. The second article covers more extensive trauma, involving multiple teeth and where significant supporting tissues are lost. It describes the replacement of teeth, including the hard and soft tissues with implant supported restorations, whilst highlighting the need for a multidisciplinary team in severe cases.

The restorative management of the deep overbite.

A deep overbite is where the vertical overlap of the upper and lower incisors exceeds half of the lower incisal tooth height. Problems associated with the deep overbite can include soft tissue trauma, lack of inter-occlusal space and tooth wear, all of which can present significant challenges for the restorative dentist. While management options very much depend on the nature of the situation and patient's symptoms, options may range from provision of a simple removable appliance or splint and non-surgical periodontal therapy, to multidisciplinary care involving orthodontics, orthognathic surgery and restorative dentistry. Restorative management may involve an increase in the occlusal vertical dimension with fixed restorations or removable prostheses, and careful assessment and treatment planning is essential. This article discusses the aetiology and restorative management strategies for deep and traumatic overbites.

Intra-articular nodular fasciitis: an unexpected diagnosis for a joint lesion: a case report.

UNLABELLED: Pathological lesions in and around a joint can arise from underlying dermis, subcutis, deep muscle, bone or synovium. Clinical presentation can include joint pain, joint swelling, palpable masses and mechanical restriction. Whilst giant cell tumour of tendon sheath, pigmented villonodular synovitis, synovial chondromatosis, lipoma arborescens, juxta articular myxomas and inflammatory arthritis are the better-known conditions of the joint. Intra-articular nodular fasciitis, on the other hand, is less well recognized both clinically and radiologically. It is rarely seen in routine practice and is only described in case reports in the literature. Due to the non-specific clinical and radiological findings as well as the unfamiliarity with the entity, the diagnosis of intra-articular nodular fasciitis is usually clinched only after histological examination. We present a case of intra-articular nodular fasciitis arising in the knee joint which was not suspected clinically or radiologically. KEY WORDS: Intra-articular, nodular fasciitis, joint, knee, MRI.

Retracted: Nurses learning in the workplace: a comparison of workplace attributes in acute care settings in Australia and Singapore.

BACKGROUND: Workplaces need to foster teaching and learning interactions so staff collaborate and learn from each other. Internationally, many countries provide support to graduates and experienced staff to foster engagement necessary for learning and quality care. Workplace attributes can differ across countries depending on managerial, contextual, social and policy issues. AIM: This study compared workplace attributes of two Australian hospitals with a Singaporean hospital. METHODS: A representative sample of nurses in two acute care facilities in Australia (n = 203) and a comparable facility in Singapore (n = 154) during 2010 and 2011 responded to a survey requesting demographic data and responses about workplace attributes. Attributes were determined through validated tools that measure staff perception of support when facilitating others learning (Support Instrument for Nurses Facilitating the Learning of Others) and the clinical learning organizational culture (Clinical Learning Organizational Culture Survey). RESULTS: Results indicated Singaporean nurses rated perception of acknowledgement, workload management and teamwork support in facilitating learners in their hospital as significantly better than the Australian cohort despite similar provisions for support and development. There were no significant differences across the two sites in the clinical learning culture. LIMITATIONS: Analysis across three health facilities only provides a snapshot. Targeting more facilities would assist in confirming the extent of reported trends. CONCLUSIONS: Findings indicate differences in nurses' perceptions of support when facilitating learners. Further exploration of Singaporean nurses' increased perceptions of support is worthy. Clinical learning organizational culture findings across Australian and Singaporean acute care facilities suggest common attributes within the nursing profession that transcend contextual factors, for example, a strong sense of task accomplishment. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Nurses across both countries demonstrate strengths in accomplishing tasks but less so in recognizing nurses' contributions that may also impact nurses' influence in the practice context. As these attributes are common, nursing can collectively lobby and develop policy, thereby strengthening their cause to be recognized.

Amelogenesis imperfecta - lifelong management. Restorative management of the adult patient.

The biggest challenge restorative dentists face in rehabilitating patients with amelogenesis imperfecta (AI) is trying to restore aesthetics, function and occlusal stability while keeping the treatment as conservative as possible. The goals of treatment should be to prolong the life of the patient's own teeth and avoid or delay the need for extractions and subsequent replacement with conventional fixed, removable or implant retained prostheses. In order to achieve these goals a stepwise approach to treatment planning is required starting with the most conservative but aesthetically acceptable treatment. This article discusses the management of AI and presents the various treatment options available for restoring the adult patient who presents to the dentist with AI.

Gingival recession: part 2. Surgical management using pedicle grafts.

This paper is the second in a three part series looking at the aetiology and management of gingival recession. Part one discussed the aetiology and non-surgical management and this part aims to discuss the use of pedicle soft tissue grafts in the treatment of gingival recession. This article also considers the factors affecting the outcome of surgical procedures used to treat localised recession defects. The third paper in this series will consider the use of free soft tissue grafts and guided tissue regeneration.

Gingival recession: part 3. Surgical management using free grafts and guided tissue regeneration.

This paper is the third in a three part series looking at the aetiology and management of gingival recession. Part 1 in this series discussed the aetiology of gingival recession and the non-surgical management. Part 2 discussed in detail the factors affecting the outcome of periodontal surgery and the use of pedicle flaps. This paper aims to discuss the surgical options available to correct localised recession defects using free grafts and guided tissue regeneration.

Gingival recession: Part 1. Aetiology and non-surgical management.

Gingival recession is a common finding in many patients. Some patients will not be concerned whereas others will have aesthetic concerns or complain of sensitivity. This paper highlights the aetiology of gingival recession, the treatment options available to treat any associated sensitivity and the non-surgical treatment options available to restore aesthetics in patients with gingival recession. Subsequent papers in this series discuss the surgical treatment options available to correct localised recession defects.

Resin bonded bridges: techniques for success.

Resin bonded bridges are a minimally invasive option for replacing missing teeth. Although they were first described over 30 years ago, evidence regarding their longevity remains limited and these restorations have developed an undeserved reputation for failure. This article provides a brief review of the literature regarding bridge success and continues to highlight aspects of case selection, bridge design and clinical procedure which may improve outcome.

Microbiological cure times in acanthamoeba keratitis.

AIMS: The purpose of this study was to estimate the duration of treatment necessary for sequential acanthamoeba laboratory tests from corneal scrapings to become negative, and to assess predictors that affect this duration period. METHODS: We included all patients with at least one positive acanthamoeba culture or Giemsa stain at the F.I. Proctor Foundation Microbiology Laboratory from 1996 to 2009. A parametric survival analysis was performed among patients with repeat cultures to assess significant predictors for extended clearance time. Simulations were performed to estimate clearance time in the entire patient population, assuming imperfect sensitivity. RESULTS: Thirty-seven patients with laboratory evidence of acanthamoeba had testing at 69 time points. The median clearance time among eyes with repeat cultures was 42.5 days (interquartile range (IQR) 22.0-82.0 days; unadjusted parametric model). Initial visual acuity was the only predictor significantly associated with clearance time in univariate analyses (P<0.0001). Using initial visual acuity as a predictor for clearance time among the entire patient population, the estimated clearance time decreased to 38.7 days (95% confidence interval (CI) 27.9-53.5 days). When the imperfect sensitivity of the culture technique was also taken into account, the estimated clearance time was 44.1 days (95% CI 31.9-61.0 days). CONCLUSION: The duration of infection with acanthamoeba keratitis undergoing treatment has not been well characterized. In this report we estimate a median clearance time of approximately 6 weeks, with an IQR of 22-82 days.

Investigating the health profile of patients with end-stage renal failure receiving peritoneal dialysis: a cluster analysis.

AIM: To determine whether the patients with end stage renal failure can be differentiated into several subtypes based on five main variables. BACKGROUND: There is a lack of interventional research linking to clinical outcomes among the patients with end stage renal failure in Hong Kong and with no clear evidence of differences in terms of their clinical/health outcomes and characteristics. DESIGN: A cross-sectional survey. METHOD: Data were collected using a structured questionnaire. One hundred and fifty-three patients with end stage renal failure were recruited during 2007 at three renal centres in Hong Kong. Five main variables were employed: predisposing characteristic, enabling resources, quality of life, symptom control and self-care adherence. RESULTS: A cluster analysis yielded two clusters. Each cluster represented a different profile of patients with end stage renal failure. Cluster A consisted of 49.7% (n = 76) and Cluster B consisted of 50.3% (n = 77) of the patients. Cluster A patients, more of whom were women, were older, less educated, had higher quality of life scores, a better adherence rate and more had received nursing care supports than patients in Cluster B. CONCLUSIONS: We have identified two groupings of patients with end stage renal failure who were experiencing unique health profile. Nursing support services may have an effect on patient health outcomes but only on a group of patients whose profile is similar to the patients in Cluster A and not for patients in Cluster B. A clear profile may help health care professional make appropriate strategies to target a specific group of patients to improve patient outcomes. RELEVANCE TO CLINICAL PRACTICE: The identification of risk for future health-care use could enable better targeting of interventional strategies in these groups. The results of this study might provide health care professionals with a model to design specified interventions to improve life quality for each profile group.

New teeth from old: treatment options for retained primary teeth.

Retention of primary teeth beyond their expected exfoliation date is encountered relatively frequently. Most commonly this is due to absence of the permanent successor. In this article patient assessment and the restorative treatment options are discussed with particular emphasis on retention of the primary tooth/teeth in the medium to long-term. The restorative techniques that may be used to improve aesthetics and function of retained primary teeth are illustrated. Consideration of this minimally invasive approach is commended in such cases.